Provider Demographics
NPI:1306383005
Name:KING CARE PHARMACY LLC
Entity Type:Organization
Organization Name:KING CARE PHARMACY LLC
Other - Org Name:YOUR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MASOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGHSOODI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:517-614-1207
Mailing Address - Street 1:713 N WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-2242
Mailing Address - Country:US
Mailing Address - Phone:517-253-7512
Mailing Address - Fax:517-253-7514
Practice Address - Street 1:713 N WAVERLY RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-2242
Practice Address - Country:US
Practice Address - Phone:517-253-7512
Practice Address - Fax:517-253-7514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010110913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1306383005Medicaid